13C glucose breath test for the diagnosis of diabetic indications and monitoring glycemic control

ABSTRACT

Use of  13 C glucose in an analytical assay to monitor glucose metabolism by measurement of labeled exhaled CO 2  is provided. A breath test and kit for performing the breath test are described for the diagnosis of diabetic indications and monitoring of glycemic control. The breath test utilizes the measurement of expired  13 C-labeled CO 2  following the ingestion of a  13 C-enriched glucose source.

REFERENCE TO RELATED APPLICATIONS

[0001] This application is a continuation-in-part of U.S. applicationSer. No. 09/674,806, filed Feb. 8, 2001, as a U.S. National PhaseApplication of International Application PCT/IB99/00933, filed May 9,1999, which claims priority to U.S. Provisional Application No.60/084,482, filed May 6, 1998. The disclosure of each of the aboveapplications is incorporated herein by reference in their entirety.

FIELD OF INVENTION

[0002] Use of ¹³C glucose in an analytical assay to monitor glucosemetabolism by measurement of labeled exhaled CO₂ is provided. A breathtest and kit for performing the breath test are described for thediagnosis of diabetic indications and monitoring of glycemic control.The breath test utilizes the measurement of expired ¹³C-labeled CO₂following the ingestion of a ¹³C-enriched glucose source.

REFERENCES

[0003] The following references are referred to by their numbers inparenthesis in this specification.

[0004] Martin B C, Warram J H, Krolewski A S, et al. Role of glucose andinsulin resistance in development of type 2 diabetes mellitus: resultsof a 25-year follow-up study. Lancet 1992; 340: 925-9.

[0005] 2. Lillioja S, Mott D M, Spraul M, et al. Insulin resistance andinsulin secretory dysfunction as precursors of non-insulin-dependentdiabetes mellitus; prospective studies of Pima Indians. N Engl J Med1993; 329: 1988-92.

[0006] 3. Beck Nielsen H, Groop L C. Metabolic and geneticcharacterization of pre-diabetic states. Sequence of events leading tonon-insulin-dependent diabetes mellitus. J Clin Invest 1994; 94:1714-21.

[0007] 4. Matthaei S, Stumvoll M, Kellerer M, et al. Pathophysiology andpharmacological treatment of insulin resistance. Endocr Rev 2000; 21:585-618.

[0008] 5. The Expert Committee on the Diagnosis and Classification ofDiabetes Mellitus. Report of the expert committee on the diagnosis andclassification of diabetes mellitus. Diabetes Care 2001; 24(suppl 1).

[0009] 6. Harris M I. Undiagnosed NIDDM: clinical and public healthissues. Diabetes Care 1993, 16: 642-52.

[0010] 7. World Health Organization. Prevention of diabetes mellitus:report of a WHO study group. Geneva: WHO, 1994; technical report seriesNo. 844.

[0011] 8. Meltzer S, Leiter L, Daneman D, et al. 1998 clinical practiceguidelines for the management of diabetes in Canada. Can Med Assoc J1998; 159 (suppl 8): S1-29.

[0012] 9. Matthews D R, Hosker J P, Rudenski A S, et al. Homeostasismodel assessment: insulin resistance and beta-cell function from fastingplasma glucose and insulin concentrations in man. Diabetologia 1985; 28:412-19.

[0013] 10. Haffner S M, Gonzales C, Miettinene H, et al. A prospectiveanalysis of the HOMA model: the Mexico City Diabetes Study. DiabetesCare 1996: 19: 1138-41.

[0014] 11. Bonora E, Targher G, Alberiche M, et al. Homeostasis modelassessment closely mirrors the glucose clamp technique in the assessmentof insulin sensitivity. Diabetes Care 2000; 23: 57-63.

[0015] 12. World Health Organization. Definition, diagnosis andclassification of diabetes mellitus and its complications: Report of aWHO Consultation. Part 1. Diagnosis and classification of diabetesmellitus. Geneva: WHO, 1999.

[0016] 13. Ganda O P, Day J L, Soeldner J S, et al. Reproducibility andcomparative analysis of repeated intravenous and oral glucose tolerancetests. Diabetes 1978; 27:715-25.

[0017] 14. Riccardi G, Vaccaro O, Rivellese A, et al. Reproducibility ofthe new diagnostic criteria for impaired glucose tolerance. Am JEpidemiol 1985; 121: 422-9.

[0018] 15. Ko GTC, Chan JCN, Woo J, et al. Use of the 1997 AmericanDiabetes Association Diagnostic criteria for diabetes in a Hong KongChinese population. Diabetes Care 1998; 21: 2094-7.

[0019] 16. Ko GTC, Chan J C N, Woo J, et al. The reproducibility andusefulness of the oral glucose tolerance test in screening for diabetesand other cardiovascular risk factors. Ann Clin Biochem 1998; 35: 62-7.

[0020] 17. Gabir M M, Hanson R L, Diabelea D, et al. The 1997 AmericanDiabetes Association and 1999 World Health Organization criteria forhyperglycemia in the diagnosis and prediction of diabetes Diabetes Care2000; 23: 1108-12.

[0021] 18. Radziuk J. Insulin sensitivity and its measurement:structural commonalities among the methods. J Clin Endocrinol Metab2000; 85: 4426-33.

[0022] 19. CDC Diabetes Cost-Effectiveness Study Group. Thecost-effectiveness of screening for type 2 diabetes. JAMA 1998; 280:1757-63.

[0023] 20. Hosker J P, Matthews D R, Rudneski A S, et al. Continuousinfusion of glucose with model assessment: measurement of insulinresistance and β-cell function in man. Diabetologia 1985; 28: 401-11.

[0024] 21. Emoto M, Kawagishi T, Nishizawa Y, et al. Homeostasis modelassessment as a clinical index of insulin resistance in type 2 diabeticpatients treated with sulfonylureas. Diabetes Care 1999; 22:818-22.

[0025] The entire disclosure of each of the above-referencedpublications, patents and patent applications is incorporated herein inits entirety.

BACKGROUND OF THE INVENTION

[0026] Glucose tolerance is defined as the ability to properly utilizeglucose. Diabetes is not a single disease, but an array of diseases thatexhibit the common symptom of glucose intolerance, an impairment inglucose utilization.

[0027] The prevalence of diabetes in the general population isapproximately 6-7%. Only about half of diabetics are actually diagnosed.Studies have shown that rates for persons with glucose intolerance areequal by sex and greater for blacks than for whites.

[0028] In general, the following types of diabetes have been recognized:type I diabetes mellitus, type II diabetes mellitus, secondary diabetesmellitus, impaired glucose tolerance and gestational glucose mellitus.The general characteristics of the symptoms of diabetes include thefollowing:

[0029] Polyuria (high urine blood volume)

[0030] Hyperglycemia (high blood glucose levels)

[0031] Glucosuria (loss of glucose in urine)

[0032] Polydipsia (excessive thirst)

[0033] Polyphagia (excessive hunger)

[0034] Sudden weight loss

[0035] It has been observed that complications resulting from diabetesmellitus are the third leading cause of death in most developedcountries. Diabetes is a risk factor for a variety of conditionsincluding coronary heart disease, cerebrovascular stroke, neuropathy(nerve damage), nephropathy (kidney damage), retinopathy (eye damage),hyperlipidemia (excessive blood lipids), angiopathy (damage to bloodvessels) and infection.

[0036] A number of different methods exist for determining a conditionof intolerance for glucose. These include postprandial blood glucose,oral glucose tolerance test (OGTT), O'Sullivan glucose tolerance test(gestational test), hemoglobin Alc (Hb A¹, Hb A_(1c)), islet cellantibodies, glutamic acid decarboxylase (GAD) antibodies and insulinantibodies. Diabetes, however, is most readily detected when thecarbohydrate metabolic capacity is tested. This is done by stressing thesystem with a defined glucose load as in the oral glucose tolerance test(OGTT).

[0037] The OGTT has been criticized, however, because many of thevariables affecting test results are difficult to control. For instance:patients must be on a standardized carbohydrate diet at least three daysbefore the test; the test requires an 8 to 16 hour fast; the test shouldonly be performed on ambulatory patients; stress should be avoided;exercise should be avoided; various hormone imbalances can affectvalidity such as with: thyroxine, growth hormone, cortisol andcatecholamines; various drugs and medications can affect validity suchas: oral contraceptives, salicylates, nicotinic acid, diuretics andhypoglycemics; and evaluation should normally be corrected for age. Thegreatest disadvantage of the OGTT is that it is poorly reproducible andthis limits its diagnostic usefulness.

[0038] Type 2 diabetes is a common condition, associated withsignificant morbidity and mortality. It is generally acknowledged thatovert type 2 diabetes is preceded by a period of glucose intolerancewhich itself is preceded by a significant period of insulin resistance(1-5). It is now further recognized that typical diabetic complicationscan begin to develop during this “pre-diabetic” phase (3, 6). Theidentification of persons at risk of developing overt type 2 diabeteshas therefore taken on even greater importance. It has been suggestedthat if such persons could be easily identified, a lifestylemodification strategy could be implemented which might prevent theirprogression to type 2 diabetes with its attendant morbidities.

[0039] Because of the public health importance of type 2 diabetes,regular screening for this condition is now advocated (5, 7, 8).However, such screening programs, whether by fasting plasma glucose orby the 75-g OGTT, only identify diabetic or glucose-intolerant patients.The homeostasis model assessment (HOMA) index has been advocated as amethod of detecting persons with insulin resistance and thereforepresumably at risk of progressing to overt type 2 diabetes (9-11).However, the HOMA index requires a serum insulin measurement and, someargue, the use of a computer program. Thus, this index is not as simpleor accessible as a fasting blood glucose level. Similarly, the goldstandard euglycemic, hyperinsulinemic clamp is clearly not appropriatefor mass screening campaigns.

[0040] The current methods of diagnosing diabetes involve eitherinvasive testing (i.e., repeated blood collections), or use blood-bornemarkers (i.e., glycosylated proteins, or antibodies) which offer anindirect assessment of glucose regulation. Accordingly, it is an objectof the present invention to avoid the need for invasive testing or theuse of blood-borne markers in determinations of glucose regulation.

SUMMARY OF THE INVENTION

[0041] The above and other objects of the invention are attained by a¹³C breath test and a kit for determining glucose regulation in apatient in need thereof.

[0042] Based on our experience in the use of ¹³C breath tests, wepropose a simple, sensitive test of insulin resistance. In normalindividuals, in the presence of insulin, glucose is taken up by cellswhere it undergoes glycolysis and then enters the citric acid cycle oris shunted to fat synthesis. In either case, CO₂ is produced as ametabolic by-product. This CO₂ then re-enters the circulation and iseliminated in the lungs. We found that if glucose was labeled with ¹³C,the resultant CO₂ could be detected in the expired air. In type 2diabetes and other states of insulin resistance, glucose uptake isimpaired and the generation of ¹³Co₂ is likewise blunted. Accordingly,we have developed a ¹³C-glucose breath test for the diagnosis of type 2diabetes and insulin resistance. In particular, the test provides ameans to detect insulin resistance when blood glucose levels are stillin the normal range and before β-cell destruction leading to diabeteshas occurred. Early detection of insulin resistance will allowintervention in time to prevent the development of type 2 diabetes. Inaddition, the test allows the success of intervention therapies,including diet and exercise. to be monitored.

[0043] An analytical assay is described that is based on the use ofnon-radioactive ¹³C. Labeled expired ¹³CO₂ is measured in the presentassay. Isotope ratio mass spectroscopy (IRMS) is used as a detectionmethod for ¹³C, a non-radioactive isotope that occurs naturally in foodand animal tissues. Non-dispersive infrared spectroscopy (NDIRS)analysis and analysis methods known in the art may be employed. The testprotocol is as follows: after an overnight fast, the oral dose of ¹³Cuniformly labeled glucose (containing about 25 mg of ¹³C glucose incombination with about 15 g of unlabeled glucose in 100 ml of tap water)is administered. Breath samples will be collected before the dose andthen 1½ hours after ¹³C glucose ingestion. Levels of ¹³CO₂ in expiredair will be measured by an IRMS method.

[0044] Advantages of this test are the following:

[0045] it is practical, sensitive and specific;

[0046] the validity of the test is not influenced by stress, exercise,hormone imbalances, or some drugs and medications;

[0047] it is a non-invasive method;

[0048] it is simple to perform and can be readily used in physicians'offices or medical laboratories;

[0049] it is safe since ¹³C is a naturally occurring isotope found inall carbon-containing substances;

[0050] it involves no radioactivity, and may be used in children andwomen.

[0051] The ¹³C glucose test is safe, reliable, and specific in diagnosisof diabetes and measurement of the severity of insulin resistance inpatients. The invention is also preferred to diagnose gestationaldiabetes and to monitor glycemic control in diabetes patients. Apreferred embodiment of the invention is a kit containing the necessarymaterial for performing the described method. This kit may contain, butis not limited to, a source of ¹³C enriched glucose (preferablyuniformly labeled D-glucose); a source of unenriched glucose; and abreath collection device. The kit may also contain a set of patientinstructions for its use. In another embodiment, the kit mayadditionally contain a blood collection device, such as a lancet orhypodermic needle and vacutainer for the additional determination ofblood glucose levels.

[0052] Accordingly, in one aspect the invention provides diagnostic kitsfor the determination of glycemic control in a subject comprising: apredetermined quantity of ¹³C-enriched glucose; and a breath collectioncontainer. A plurality of breath containers and/or instructions for usemay be included. The kits may be used for the diagnosis of diabetes,insulin resistance, gestational diabetes, and the like or to determinethe adequacy of antihyperglycemic therapy.

[0053] In a further aspect, the invention provides a use of ¹³C-enrichedglucose for the determination of glycemic control in a subject.

[0054] In another aspect, the invention provides ¹³C-enriched glucosefor use in the manufacture of diagnostic kits for the determination ofglycemic control in a subject. The kits may be used for the diagnosis ofdiabetes, insulin resistance, gestational diabetes, and the like or todetermine the adequacy of antihyperglycemic therapy.

[0055] In yet a further aspect, the invention provides diagnostic kitsfor the determination of glycemic control in normal, diabetic andinsulin resistant subjects by comparing blood glucose levels with breathlevels of ¹³C-enriched CO₂

[0056] In a still further aspect, the invention provides method ofdiagnosing a condition in a subject, said condition selected from thegroup consisting of diabetes, insulin resistance impaired glucosetolerance, impaired fasting glucose and gestational diabetes, saidmethod comprising collecting a first breath sample from said subject ina first breath collection container; administering ¹³C-enriched glucoseto said subject; collecting a second breath sample from said subject ina second breath container at a time point after administration of said¹³C-enriched glucose; measuring the ¹³CO₂ in each of said first andsecond breath samples; and comparing the amount of ¹³CO₂ in said secondbreath sample with the amount of ¹³CO₂ in said first breath sample toobtain a delta value, wherein the presence of less ¹³CO₂ in said secondbreath sample compared to normal control values indicates the presenceof said condition. Using an ROC curve, a delta cutoff is chosen whereinthe sensitivity and specificity are such as to maximize diagnosticaccuracy. In particular, when the condition is insulin resistance, arange of deltas from 8 to 10 is preferred. A delta of 9 is mostpreferred.

[0057] In yet an additional aspect, the invention provides method ofpredicting a subject's risk of developing diabetes, said methodcomprising collecting a first breath sample from said subject in a firstbreath collection container; administering ³C-enriched glucose to saidsubject; collecting a second breath sample from said subject in a secondbreath container at a time point after administration of said¹³C-enriched glucose; measuring the ¹³CO₂ in each of said first andsecond breath samples; and comparing the amount of ¹³CO2 in said secondbreath sample with the amount of ¹³CO₂ in said first breath sample,wherein the presence of less ¹³CO₂ in said second breath sample comparedto normal control values indicates risk of developing diabetes. Thecomparison may be made by choosing a cutoff of ROC values wherein thesensitivity and specificity are such as to maximize diagnostic accuracy.In particular, a range of ROC's from 8 to 10 is preferred. An ROC of 9is most preferred.

[0058] The ¹³C-glucose breath test is superior to currently usedlaboratory criteria in the diagnosis of type 2 diabetes. Its predictivevalue for clinical status, as well as its correlation with the HOMAindex, make it a simple but useful test for detecting early evidence ofinsulin resistance and hence, risk for type 2 diabetes.

BRIED DESCRIPTION OF THE DRAWING FIGURES

[0059]FIG. 1: Illustrates the IRMS analysis of ¹³C glucose breathsamples from normal individuals, a gestational diabetic, and patientswith impaired glucose tolerance.

[0060]FIG. 2: Shows a representative example of breath test and bloodglucose levels of a normal individual.

[0061]FIG. 3: Illustrates breath test and blood glucose levels of adiabetic patient.

[0062]FIG. 4: Depicts breath test and blood glucose levels of an insulinresistant patient.

[0063]FIG. 5: Shows a comparison of IRMS results of an insulin resistantand a diabetic patient, and a normal individual.

[0064]FIG. 6: Illustrates the distribution of ¹³CO₂ (a) and HOMA (b)results between diabetic and non-diabetic patients. Bars indicate theupper limit of the normal range.

[0065]FIG. 7: Plots the relationship between HOMA index and ¹³C-glucosebreath test result.

[0066]FIG. 8: Illustrates the ROC curve for the ¹³C-glucose breath test.Individual points are in δ per mil.

DETAILED DESCRIPTION OF THE INVENTION

[0067] The introduction of a ¹³C breath test offers a novel,non-invasive, direct means to monitor glucose metabolism by measurementof exhaled CO₂ using highly enriched, uniformly labeled ¹³C-glucose.Glucose metabolism will generate labeled CO₂, which is then exhaled andcollected in tubes. Enrichment of labeled CO₂, over a determined timecourse, can be used as a quantitative index of glucose metabolism.Comparison is made against age-specific reference intervals.

[0068] The present invention has a number of advantages, including lowerdose of glucose needed (overcomes inconsistencies due to malabsorptivedisorders or previous gastric or intestinal surgery), reduction intesting time (from the current 2 hours required for the OGTT) and fewerinterpretational ambiguities (greater sensitivity and specificity).

[0069] The ¹³C glucose breath test is based on the metabolism ofglucose. Following a baseline breath sample, a ¹³C glucose solutioncontaining about 25 mg of ¹³C glucose in combination with about 15 g ofunlabeled glucose in 100 ml of tap water is administered. Breath sampleswill be obtained before the dose and then 12 hours after ¹³C glucoseingestion. Measurement of the expired air will be detected by an isotoperatio mass spectroscopy assay method. Elevated or excessive breath of¹³CO₂ concentrations will be seen in individuals who have normal glucosemetabolism.

[0070] The ¹³C-glucose breath test provides a more sensitive anddiagnostically accurate indicator of the presence of type 2 diabetesthan do currently used common methodologies. However, a problem arisesin that the definition of diabetes is made on the basis of fastingplasma glucose or glucose-tolerance test values. Thus, these tests arethe de facto “gold standards” and theoretically should be the mostaccurate. In the well-characterized group of diabetic patients studiedin this investigation, the pitfalls of a single fasting blood glucosevalue or a glucose tolerance test are evident. Indeed, numerous reportsof the poor overall diagnostic accuracy of the glucose tolerance test orfasting plasma glucose as a diagnostic tool for diabetes exist (13-17).Moreover, the requirement for confirmation of an abnormal fasting plasmaglucose reduces sensitivity of this test albeit at a gain inspecificity. It could be argued, however, that for screening purposes,sensitivity is perhaps preferable to specificity. However, because ofthe theoretical advantage of diagnosing subjects at risk of diabetesprior to the actual onset of the disease, various indices of insulinresistance or glucose intolerance have been devised (for a review see18). The hypothesis associated with these latter measurements is thatinsulin resistance and abnormalities in glucose homeostasis occur wellbefore the onset of overt type 2 diabetes. If patients demonstratingsuch abnormalities can be detected through screening programs, it hasbeen suggested that the development of overt diabetes may be preventedor delayed (4, 5, 19). The importance of such an approach is furtherunderscored by the finding that at the time of type 2 diabetes onset, asignificant number of patients already have diabetic complications (3,6).

[0071] In order to address the need for a relatively simple index ofinsulin resistance, the HOMA index was developed. This index has beenshown to correlate with results from the gold-standard hyperinsulinemic,euglycemic clamp (9, 11, 20, 21). Although the HOMA index wassignificantly higher in the diabetics in this study, it wasdiagnostically inferior in all aspects to the ¹³C-glucose breath test.Indeed, when both the HOMA index and the ¹³C-glucose breath test resultswere entered into a logistic regression which included fasting bloodsugar, age, sex and BMI as variables, only the ¹³C-glucose breath testgave a statistically significant partial correlation coefficient.Similarly, when each of the two variables of interest was individuallyincluded in a similar logistic regression, which also included the 2hour OGTT value as a further variable, the ¹³C-glucose breath testretained a statistically significant predictive value whereas the HOMAindex did not. Indeed, in all possible iterations of the logisticregression, the ¹³C-glucose breath test was always the strongestpredictor of diabetic status. Although it may be argued that a HOMA isan easier test, requiring only a single blood sample, there aredisadvantages to this test as well. First of all, a serum insulinmeasurement must be carried out in a reasonably advanced medicallaboratory by trained technicians. This adds time and cost to thescreen. The ¹³C-glucose breath test, however, can be analyzed using apoint of care instrument that requires very little training to use.Thus, screening can be carried out in the field with results availablealmost as soon as the last breath sample is complete. The HOMA indexrequires blood samples with the attendant infectious precautions. The¹³C-glucose breath test is carried out on breath and therefore onlygeneral infectious precautions are necessary. Similarly, phlebotomyrequires trained medical personnel whereas the ¹³C-glucose breath testdoes not necessarily require any supervision—a package insert canprovide all the necessary instructions. Thus, the ¹³C-glucose breathtest can also be made available to remote locations via post. Finally,although the HOMA provides added diagnostic accuracy to the diagnosis ofdiabetes when compared to a fasting blood sugar, as can be seen fromTable 1, the traditional OGTT is superior to both. Compared to the OGTT,however, the ¹³C-glucose breath test has even greater accuracy and hasthe advantage of requiring a lower glucose load and a shorter timerequirement along with all the other advantages listed above. One finalconsideration is the possibility of false negative results with thebreath test in subjects with delayed gastric emptying. Given therelatively low volume and lower osmolarity of the breath test comparedwith the OGTT, problems with gastric emptying are likely to be less thanthose associated with the OGTT. Indeed, based on 1, 1.5 and 2 hourbreath test values in this study, no subjects showed evidence of delayedgastric emptying. As this test is most likely to find use early in thecourse of insulin resistance/type 2 diabetes, it is unlikely thatdiabetic gastroparesis will be a significant confounder. Thus, the¹³C-glucose breath test offers a simple, sensitive and accurate methodfor the diagnosis of type 2 diabetes.

[0072] In terms of insulin resistance, studies are underway to validatethe ¹³C-glucose breath test against the hyperinsulinemic, euglycemicclamp. However, even with the current results, there is evidence thatthe ¹³C-glucose breath test is an indicator of insulin resistance.First, the ¹³C-glucose breath test results do correlate with the HOMA.Secondly, there is a strong correlation between the breath test and bodymass index whereas the correlation between the HOMA index is lessstrong. Third, the superior diagnostic parameters of the breath test andthe fact that a type 1 diabetic had a breath result of <1.2 show acorrelation between insulin resistance and the ¹³C-glucose breath testresult. Finally, the underlying principal of the ¹³C-glucose breath testis based on resistance to glucose uptake by target tissues. Thus, the¹³C-glucose breath test also offers a simple, sensitive, specific testfor the diagnosis of insulin resistance.

[0073] One final advantage of the ¹³C-glucose breath test is itsapplication for following insulin resistance. This test has thepotential to allow the effectiveness of various interventions in type 2diabetes to be monitored. Whether these interventions be lifestyle orpharmacological, the ¹³C-glucose breath test offers a sensitive, dynamicmethod to assess effectiveness of type 2 diabetes treatments.

[0074] Thus, the ¹³C-glucose breath test may be used not only todiagnose diabetes, but also to determine insulin sensitivity and insulinresistance. The test may reliably be used to diagnose other difficult todetect pre-diabetic conditions. Thus, it is a useful tool to determinewhether a patient is at risk of developing diabetes.

[0075] It is important that any diagnostic test procedure havediagnostic accuracy, i.e., that it accurately predicts positive andnegative values. The receiver operated characteristics (ROC) valuedescribes the balance between the sensitivity (i.e., the number of hitsdetected) and the specificity (i.e., the accuracy) of a test. These twovariables may also be considered positive predictive value and negativepredictive value, and are correlated with diagnostic accuracy. The ROCcurve shows the relationship of the probability of a positive test,given no disease, to the probability of a positive test, given disease.An ROC cutoff value is chosen to maximize diagnostic accuracy of thetest in question.

[0076] The following examples serve to illustrate the present invention.These examples are not intended to limit the scope of the invention inany manner.

EXAMPLE 1

[0077] Sample Assay for Diagnosis of a Patient

[0078] Experimental Procedure

[0079] Medical History

[0080] Medical history is taken and includes, but is not limited to: theabsence of active pulmonary disease, no history of heart, liver, orrenal failure, and no use of insulin or oral medications for thetreatment of diabetes.

[0081] Physical Examination and Laboratory Tests

[0082] No physical examination or laboratory tests, including bloodsampling, is required.

[0083] Dietary Control

[0084] It is determined that all participants have fasted overnightprior to commencement of the test.

[0085] Patient Control

[0086] Participants are not permitted to eat, drink, or smoke during thetest. All patients are required to remain sedentary for the duration ofthe test. Small amounts of water are allowed.

[0087] Assay Procedure

[0088] Patients fast for at least 8 hours before this test.

[0089] A sample set of patient instructions is given below:

[0090] Step 1: COLLECT FIRST BREATH SAMPLE

[0091] Remove the screw cap from the collection tube.

[0092] Take a normal breath and then exhale fully 4 to 8 seconds througha straw into the bottom of the collection tube.

[0093] Immediately replace the screw cap on the collection tube andtighten until snug (do not overtighten).

[0094] Affix the completed green label to the collection tube.

[0095] Step 2: DRINK THE SOLUTION

[0096] Prepare the solution by adding tap water to the fill line on theplastic container. Mix until completely dissolved and then drink theentire solution.

[0097] Wait 1½ hours.

[0098] Step 3: COLLECT THE SECOND BREATH SAMPLE

[0099] One and one half hours after drinking the solution, collect thesecond breath sample into the collection tube following the samedirections as for the first breath sample in step 1.

[0100] Affix the completed yellow label to the tube.

[0101] Step 4: RETURN THE SAMPLES FOR ANALYSIS

[0102] Insert the 2 collection tubes along with the signed and completedregistration card in the mailing box.

[0103] Return the mailing box as instructed to the site of dispensing.

EXAMPLE 2

[0104] Breath Test Administration

[0105] Patients are given an exetainer tube with the screw cap removed.Using the straw, they are asked to breathe into the tube, exhalingnormally, for 4 to 8 seconds. Next, each patient is instructed to drinka solution containing about 25 mg of uniformly labeled ¹³C glucose incombination with about 15 g of unlabeled glucose in 100 ml of tap water.After 12 hours, the patients are given a new tube to breathe in asdescribed above. The breath collection is then complete.

[0106] Storage and Shipping

[0107] Breath test tubes are typically labeled with the patient's nameand identification number and shipped to an analytical laboratory foranalysis. No refrigeration or special storage techniques are necessary.

EXAMPLE 3

[0108] Analytical Methodology

[0109] Breath specimens are analyzed by isotope ratio mass spectroscopy.NDIRS is also a preferred method to analyze breath test samples. Othermethods known in the art may also be used.

[0110] Statistical Analysis

[0111] The sensitivity, specificity, positive and negative predictivevalues of the breath test are compared to that of the oral glucosetolerance test. Receiver operated characteristic curve (ROC) analysis isperformed to confirm the discrimination between type 2 diabetes orgestational diabetes and individuals with normal glucose metabolism.

EXAMPLE 4

[0112] Basis of the Method of IRMS

[0113] Isotope ratio mass spectroscopy (IRMS) is a highly precise methodof analysis which is able to measure small samples (low nanogramamounts). For example, ¹³C/¹²C ratios are determined on a mono-carbonmolecule; CO₂ gas. The CO₂ gas can be directed to the spectrometer bymeans of a continuous flow IRMS (also called CF-IRMS).

[0114] The statistical combination of the isotopes of carbon (¹²C and¹³C) and oxygen (¹⁶O, ¹⁷O, ¹⁸O) to generate the CO₂ molecules gives riseto the formation of various isotopomers whose molecular weights are 44,45, and 46, respectively. Thus, for measuring carbon isotope ratios, 3ion beams are generated and recorded in the IRMS, corresponding to themasses of the various isotopomers of CO₂.

[0115] In order to obtain a high precision and a high accuracy,reference gases of absolutely known isotopic composition are used and adual inlet system allows an alternative admission of both sample andreference gases into the ionization source via a gas-switching valve.The measurement of the various ion beams allows for the calculation ofthe ¹³C enrichment of the sample. The value of this calculation is givenδ¹³C(‰) notation. The ¹³C abundance is expressed as δ¹³C(‰) according tothe following:

δ¹³C(‰)=([¹³C/¹²C)sample/(¹³C/¹²C)PDB]−1)×1000

[0116] This δ¹³C(‰) value measures the variations in parts per thousandof the carbon isotope ratio from the standard. For carbon, PDB wasselected as the international reference. PDB is Pee Dee Belemnitella (afossil from the Pee Dee geological formation in South Carolina). The¹³C/¹²C ratio from the calcium carbonate of this fossil is 0.011237.Compared to PDB, most of the natural compounds display a negative deltavalue. In the above equation, ¹³C/¹²C refers to the isotopomers.

[0117] Using the breath test of this invention, IRMS is an examplemethod to diagnose type 2 and gestational diabetes, and for monitoringglycemic control of diabetes patients.

EXAMPLE 5

[0118]¹³C Glucose Breath Test Results of Normal, Gestational Diabetesand Impaired Glucose Tolerance Patient

[0119] Example 4 describes a method to analyze breath samples of thisinvention. FIG. 1 shows the mean (±SD) Delta per mil over Baseline (DOB)of the normal population. Also shown are the DOB's of a gestationaldiabetic and impaired glucose tolerance patients. Breath samplescollected 0, 1, 1.5 and 2 hours according to the protocol were analyzedby IRMS. IRMS analysis of the collected breath samples can be performedon various instruments including, but not limited to, the AP2003 andAP2002 (Analytical Precision Ltd.), ABCA (POZ Europa) and the Breath MAT(Finnigan MAT). The DOB values of the gestational diabetes and theimpaired glucose tolerance patients are well below the DOB of the normalpopulation (FIG. 1). The impaired glucose tolerance diagnosis wasinitially determined by OGTT, the gestational diabetes screen was usedto confirm gestational diabetes.

[0120] Impaired glucose tolerance (IGT) refers to a condition in whichblood sugar levels are higher than normal, but are not high enough to beclassified as diabetes. IGT is a major risk factor for type 2 diabetes.IGT is present in about 11 percent of adults, or approximately 20million Americans. About 40-45 percent of persons age 65 years of age orolder have either type 2 diabetes or IGT. A person is currentlydiagnosed with IGT when the 2-hour glucose results from a glucosetolerance test are greater than 7.8 mmol/L, but less than 11.0 mmol/L. Awoman is diagnosed with gestational diabetes when she is pregnant andhas any two of the following: a fasting plasma glucose of more than 5.3mmol/L, a 1-hour glucose level of more than 10.6 mmol/L, a 2-hourglucose level of more than 8.9 mmol/L. However, as this method ofdiagnosis is invasive, the breath tests of the current invention is thepreferred diagnosis method. The ¹³C glucose breath test is sensitive,accurate and non-invasive.

EXAMPLE 6

[0121]¹³C Glucose Breath Test Results of a Normal, Insulin Resistant andDiabetes Patient

[0122] In this example, both breath test and blood glucose levels weredone on a normal, diabetic and insulin resistant patient. FIG. 2 showsthe DOB of 0, 1, 1.5 and 2 hours breath samples of a normal subjectanalyzed by IRMS. The blood glucose level of this normal individual isalso displayed.

[0123]FIG. 3 illustrates the breath test and blood glucose levels of adiabetic patient. The DOB of the breath samples are significantly lowerthan the DOB of the normal individual (FIG. 2), the blood glucose levelsare typical of a diabetic patient.

[0124] In FIG. 4, the breath test and blood glucose levels of aninsulin-resistant patient are depicted. The DOB of these breath samplesare significantly lower than the normal DOB (FIG. 2), the blood glucoselevels are typical of an insulin-resistant patient.

[0125] These results demonstrate one preferred utility of the breathtest of the current invention to diagnose diabetes and insulinresistance. In another aspect of the invention, the areas between thebreath test and blood glucose test curves can be used to diagnosepatients with insulin resistance or diabetes and confirm glucosetolerance in normal individuals by the comparison of the areas to thedifferent groups of normal, diabetic and insulin resistant patients.

[0126]FIG. 5 illustrates the ¹³C glucose breath test results of a normalindividual, insulin resistant and diabetes patient. The DOB's of theinsulin resistant and diabetes patients is significantly lower than thatof the normal DOB results.

EXAMPLE 7

[0127] NDIRS Instrumentation

[0128] Breath test samples of the invention can also be analyzed usingNDIRS instrumentation. The course of the ¹³CO₂/¹²CO₂ ratio in breathallows for diagnosis of diabetes. NDIRS can be further used to diagnosetype 2 and gestational diabetes patients and for monitoring therapy ofdiabetes patients (glycemic control of these patients).

[0129] The metabolism of ¹³C labeled substrate leads to a differentisotope ratio. NDIRS analysis of the invention can be performed onvarious instruments, including, but not limited to, the MicroLyzer(QuinTron), UbiT-IR200 andUbiT-100 (Otsuka Pharmaceutical Co., Ltd.),the URAS 10 (Hartmann and Braun) and the Isomax 2000 (Isotechnika).

EXAMPLE 8

[0130] Hyperinsulinemic Euglycemic Clamp Method for the Measurement ofInsulin Resistance

[0131] Insulin resistance is defined as the decrease of the biologicalaction of insulin, and it mainly presents as an hyperinsulinemia. Thehyperinsulinemic euglycemic clamp is currently the reference method forquantifying insulin resistance. The clamp technique consists of infusinginsulin at a constant rate and, to prevent any decrease in the plasmaglucose level, by infusing dextrose. The rate of dextrose infused tomaintain euglycemia is an estimate of the amount of glucose, which istaken up by the tissues under the effect of a defined plasma insulinconcentration. Using several rates of insulin infusion allows theestablishment of the relationship between the whole body glucosedisposal and plasma insulin levels, and to discriminate between thestates of decreased insulin sensitivity and/or altered maximal capacityto dispose of glucose. However, the hyperinsulinemic euglycemic clampmethod is very invasive, time consuming, costly and variable. The breathtest of this invention is a preferred method to measure insulinresistance as it is reliable, sensitive, specific, cost-effective andnon-invasive.

EXAMPLE 9

[0132] Monitoring Long-term Control of Diabetes

[0133] Measuring glycated hemoglobin is a current test used formonitoring long-term control of diabetes. Glycated hemoglobins areincreased as a reflection of hyperglycemia during the life span oferythrocytes. However, different analytical methods may measuredifferent glycated hemoglobins and caution must be exercised in theinterpretation of results. HPLC or column chromatography methods used toanalyze glycated hemoglobin are also highly sensitive to variations intemperature and pH. This test is also invasive, requiring several bloodsamples. The breath test of the present invention is preferred as it isnon-invasive, sensitive, accurate and cost-effective.

EXAMPLE 10

[0134] Usefulness of ¹³C Glucose Breath Tist in Diagnosis of Diabetes

[0135] Diabetes mellitus is a group of diseases characterized by highlevels of blood glucose resulting from defects in insulin secretion,insulin action, or both. Diabetes can be associated with seriouscomplications and premature death if left undiagnosed and untreated. Ithas been estimated by the World Health Organization that the number ofpeople suffering from diabetes worldwide will more than double fromabout 135 million now to 300 million by the year 2025. Of thoseestimated to have diabetes, it is believed that approximately one thirdof those are undiagnosed. It is also known that the prevalence ofdiabetes increases with age. It is estimated that 0.16% of people underthe age of 20 have diabetes but this number dramatically increases to18.4% for people over the age of 65.

[0136] There are four types of diabetes; type 1 (insulin dependent)represents 5 to 10% of all diagnosed cases, type 2(non-insulin-dependent diabetes) represents 90 to 95% of all diagnosedcases, gestational diabetes develops in 2 to 5% of all pregnancies butdisappears when a pregnancy is over, and other specific types ofdiabetes resulting from specific genetic syndromes, surgery, drugs,malnutrition, infections and other illnesses may account for 1 to 2% ofall diagnosed cases. A number of different methods exist for determiningdiabetes. These include postprandial blood glucose, oral glucosetolerance test (OGTT), O'Sullivan glucose tolerance test (gestationaltest), hemoglobin Alc, islet cell antibodies, glutamic aciddecarboxylase (GAD) antibodies, and insulin antibodies. However,diabetes is most readily detected when the carbohydrate metaboliccapacity is tested. This is done by stressing the system with a definedglucose load as in the OGTT.

[0137] Although the OGTT is a standard test for diabetes, it has beencriticized because many of the variables affecting the test results aredifficult to control for; the standardized carbohydrate diet, eight tosixteen hour fast, stress, exercise, hormone imbalances, and variousdrugs can cause test variables. These variables lead to poorreproducibility and limit the diagnostic usefulness of this test. Inaddition, the OGTT involves the collection of numerous blood specimensmaking it an invasive procedure.

[0138] The development of a ¹³C-glucose breath test for the detection ofdiabetes offers a non-invasive method that is not affected by the abovementioned variables. ¹³C is a non-radioactive isotope that occursnaturally in food and animal tissues. In the past the disadvantage of¹³C had been the shortage of the gas isotope mass spectrometers used foranalysis. With the ready availability of the necessary instrumentationand the ¹³C-labeled compounds required, the use of ¹³C-labeled compoundsin breath tests is more feasible.

[0139] Clinical Study

[0140] Objective: The primary aim of this pilot study is to evaluate thesensitivity, specificity and reliability of a ¹³C-D-glucose breath testin the diagnosis of type 2 and gestational diabetes as compared to thealready validated glucose tolerance test that will be considered thestandard.

[0141] Design: A multi-center, blinded, non-randomized design isutilized. Only the referring physicians have knowledge of theparticipants' status. Participants undergo a glucose tolerance test.Within two weeks following, participants undergo a ¹³C-D-glucose breathtest. The findings from both tests are examined for concordance.

[0142] Study Participants: This investigation is carried out byrecruiting 50 individuals each for type 2 and gestational diabetes. Fortype 2 diabetes, the participants are suspected to be diabetic. Forgestational diabetes, the participants are women in their 24^(th) to28^(th) week of pregnancy who have presented for the standardgestational diabetes mellitus screening test. Any diagnosis of diabetesis based on the results of the glucose tolerance test.

[0143] Testing Strategy: Eligible participants, after giving informedconsent, undergo the glucose tolerance test and the ¹³C-D-glucose breathtest separated by a minimum of 24 hours and a maximum of two weeks. Theglucose tolerance test is performed according to the guidelines of theCanadian Diabetes Association (CMAJ, JAMC Oct. 20, 1998;159(8suppl):S1-S29). Briefly, for the gestational diabetes screen, theglucose tolerance test consists of the consumption of a 50 g glucosetolerance drink and the collection of a venous blood sample one hourlater for glucose determination. For the time between the drinkconsumption and the blood sampling, the participant remains sedentaryand refrains from smoking or eating. Small sips of water may be taken ifnecessary.

[0144] For type 2 diabetes, an overnight fast (10-16 hours) precedes theglucose tolerance test. A fasting glucose blood sample is drawn prior tothe consumption of a 75 g glucose tolerance drink. Two hours after theingestion of the drink, a venous blood sample is collected for glucosedetermination. For the time between the drink consumption and the bloodsampling, the participant remains sedentary and refrains from smoking oreating. Small sips of water may be taken if necessary.

[0145] The ¹³C-D-glucose breath test is preceded by an overnight fast(minimum eight hours). After fasting, the participants are required toprovide a baseline breath sample. The participants then ingest the¹³C-D-glucose drink preparation and will provide breath samples at 1,1.5, and 2 hours. During the test the participants remain sedentary andare not permitted to smoke or eat. Only small sips of water arepermitted during the test.

[0146] Overall Study Design: A total of 50 participants are investigatedeach for type 2 and gestational diabetes.

[0147] Visit One: During the recruitment process, each individual isasked to review a Participant Information Sheet and to talk with thelaboratory personnel to ensure that all eligibility requirements aremet. The individual is given an opportunity to ask questions and if theymeet all the eligibility criteria, they are asked to read and sign andInformed Consent Form.

[0148] All participants who have met the eligibility criteria and signeda consent form are tested by both the glucose tolerance test (Visit Two)and the ¹³C-D-glucose breath test (Visit Three) separated by a minimumof 24 hours and a maximum of two weeks.

[0149] Visit Two: The glucose tolerance test follows the guidelines setout by the Canadian Diabetes Association (CMAJ, JAMC Oct. 20, 1998;159(8 suppl):S1-S29). Briefly for the gestational diabetes screen, theparticipants are asked to consume a commercially available glucosetolerance drink consisting of 50 g of dextrose in 296 ml. One hourfollowing consumption, a venous blood sample is collected into ared-topped vacutainer tube. For type 2 diabetes, participants firstcomplete and overnight fast (10-16 hours) and then provide a fastingblood glucose sample. Participants then ingest a commercially availableglucose tolerance drink consisting of 75 g of dextrose in 296 mlfollowed by the collection of a venous blood sample 2 hourspost-consumption.

[0150] Visit Three: For the ¹³C-D-glucose breath test, participantsfirst complete an overnight fast (minimum of 8 hours). Participantsprovide a baseline breath sample which is followed by consumption of a¹³C-D-glucose-enriched solution containing 25 mg of ¹³C-D-glucose incombination with 15 g of unlabeled USP dextrose in 100 ml of water.

[0151] Participants then provide breath samples at 1, 1.5, and 2 hours.

[0152] Note: Visit One and Visit Two may be combined if it is moreconvenient and all the testing criteria are met.

[0153] NUMBER OF PARTICIPANTS AND TARGET POPULATION: A total of 100adult participants (18 years of age or older) who are suspected ofhaving type 2 diabetes (n=50) or are being screened for gestationaldiabetes (n=50) are recruited from those individuals presenting for theoral glucose tolerance test.

[0154] INTERIM ANALYSIS: After 25 participants are enrolled for aparticular type of diabetes, all parties are unblinded to theparticipants' status. At this point in the study, the results areevaluated. If the ¹³C-D-glucose breath test results do not correlatewith the standard, the oral glucose tolerance test, such that greaterthan 5% of the participants are reported as false negatives or falsepositives, the study is temporarily halted. If the study is halted, theprotocol is amended to reflect an adjustment in the ¹³C-D-glucose breathtest kit components such that it contains 50 mg of ¹³C-D-glucose and 15g of unlabeled USP dextrose.

EXAMPLE 11

[0155] Advantages of the ¹³C Glucose Test for the Diagnosis of Diabetes

[0156] The disadvantages of the OGTT include uncontrollable factorswhich cause variability or spurious results and the invasiveness of thetest. Other tests known in the are not specific, are invasive, arevariable and are labor intensive. The ¹³C glucose breath test of thepresent invention is sensitive, reliable and specific. The ¹³C glucosebreath test shows minimal intra-individual variation, excellentanalytical precision and breath specimens are stable for at least sixweeks at room temperature. The ¹³C glucose breath test is preferred overtests known in the art, it is non-invasive, easy to perform, has verygood sensitivity and specificity and is cost effective. A preferred useof the breath test of this invention is for the diagnosis of type 2 andgestational diabetes. This invention is also preferred to determine thelevel of insulin resistance and for monitoring the appropriateness ofthe therapy of diabetes patients.

EXAMPLE 12

[0157] Efficacy of the C-glucose Breath Test in the Detection of Type 2Diabeted and Insulin Resistance

[0158] Fifty-four diabetic subjects, aged 18-75, were recruited fromattendees of the University of Alberta Hospital diabetes educationprogram. All such subjects who took part in this study did so afterattending the program wherein their diabetic status was verified by anendocrinologist according to WHO diagnostic criteria (12). Patients withsecondary forms of diabetes or who were on medications which mightotherwise interfere with insulin sensitivity were excluded. Similarly,patients in whom a 12-hour medication-free run-in period or fast wasthought to be medically contraindicated were excluded from this study.Fifty normal subjects were recruited from the population-at-large aswell as from spouses of participating diabetic patients. We reportresults for only type 2 diabetics in this study although we have carriedout the protocol in a few carefully selected type 1 diabetics forverification. This project was approved by the Research Ethics Board ofthe University of Alberta Faculty of Medicine and all subjects gavetheir informed consent prior to participating in the study.

[0159] In this study, each subject underwent breath testing as well as astandard 75 g oral glucose tolerance test (OGTT) in random order.Following a 12-hour overnight fast, study subjects attended theUniversity of Alberta Hospital Metabolic Center at 8:00 a.m. Noanti-diabetic medications, including insulin, were taken within 12 hoursof the study and, in particular, glyburide was not taken within 24 hoursof the study. Subjects were allowed free access to water during thefast, however. At time zero of the standard glucose tolerance test, aserum insulin level was also obtained in a proportion of study subjects.This modification to the protocol was added after a planned interimanalysis indicated enhanced sensitivity of the breath test over OGTTparameters. Plasma glucose was measured by glucose oxidase methodologyand serum insulin was measured by automated immunoassay (Elecsys 2010®,Roche Diagnostic, Basel, Switzerland). For the breath test, subjectsprovided a baseline breath sample and then drank 250 ml of the breathtest solution. Serial breath samples were obtained at 1, 1.5 and 2 hoursafter consumption of the breath test solution. Capillary blood glucosereadings were obtained every 30 minutes during the 2 hours of the breathtest.

[0160] The ¹³C breath test consisted of 25 mg of ¹³C-glucose mixed with15 g of dextrose and orange flavoring. The ¹³C-glucose (MartekBiosciences Corporation, Maryland, USA) is universally labeled meaningthe ¹³C occupies all six carbon positions in the molecule. Previousoptimization studies had demonstrated that 25 mg of ¹³C-glucose wassufficient for diagnostic purposes and that 15 g of glucose provided anadequate caloric challenge. In order to carry out the test, a baselinebreath sample was obtained followed by breath samples at 1, 1.5 and 2hours following the test drink. The expired ¹³CO₂ following test drinkingestion was compared to the baseline value and results expressed as anabsolute increase in ¹³C in δ per mil. Although optimization studiessuggested 1.5 hours as the best time for breath sampling, we included 1and 2 hour time points to verify these findings. Similarly, although aprevious receiver operated characteristics (ROC) suggested 8.5 as thecutoff between normal and abnormal, and a range of useful δs is from 8to 10, we also repeated ROC analysis using the data in this study. Onthis basis a δ per mil of 9.0 was ultimately used as a cutoff betweendiabetic and non-diabetic for this experiment.

[0161]¹³CO₂ was measured in breath samples using the AP2003, an isotoperatio mass spectrometer (Analytical Precision Limited, Cheshire,England). To obtain breath sample, subjects were asked to blow the valueof a normal exhalation through a short straw into (10 ml) gas samplingtubes (Labco Exetainer® system—¹³C and gas testing vials, Labco Limited,Buckinghamshire, England). The tubes were then immediately stoppereduntil analyzed. These tubes are known to be impermeable to gases for upto 90 days following sealing. Gas sampling from the tubes occurs via aneedle in the AP2003 machine permeating a rubber membrane present in thecap of the tube. The same apparatus and overall method is commonly usedin other ¹³C breath tests such as the ¹³C urea breath test forHelicobacter pylon.

[0162] A 75 gram glucose tolerance test was carried out according tostandard protocol. As mentioned, a baseline fasting serum insulin levelwas obtained in a sub-sample of the study population. Glucose wascollected in lithium-heparin tubes and immediately assayed in order toensure no changes in apparent glucose concentration. The HOMA index wascalculated as previously described using the formula HOMA=(fastingglucose×fasting insulin)/22.5(9). A value of 2.5 or above was taken tobe indicative of insulin resistance.

[0163] All values are expressed as the mean ± SD unless otherwiseindicated. Sensitivity, specificity, positive predictive value, negativepredictive value and diagnostic accuracy were calculated according tostandard methodology. Differences in variables between groups werecompared using two-sided, unpaired t-tests, ANOVA or ANCOVA asappropriate. Post hoc testing for ANOVA was carried out using the Tukeytest. Correlations between variables were carried out using linearregression. Logistic regression was used to determine factors which mostaccurately predicted diabetic status. A p value of less than 0.05 wasconsidered statistically significant. Statistical analysis was carriedout using Statview version 5.0.1 (SAS Institute, Cary, N.C., USA).

[0164] A total of 53 diabetic, 50 normal and 5 subjects with impairedglucose tolerance were included in the primary analysis. Of this total,a subgroup of 45 individuals (21 diabetic, 24 normal) underwentsimultaneous measurement of fasting serum insulin along with fastingplasma glucose in order to calculate a HOMA. Mean age of diabeticpatients was 54±11 and the mean age of normals was 44±14 (p<0.0001 fordifference). Body mass index (BMI) of diabetics was 31.6±5.5 and that ofnormals 28.8±5.2 (p=0.011). Although there were differences betweendiabetics and normals in terms of age and BMI, using age and/or BMI ascovariates did not significantly affect the results.

[0165] A scatter diagram for diabetics and normals for both the ¹³Cbreath test and the HOMA are shown in FIGS. 5a and 5 b. From thisfigure, it can be seen that there is significantly less overlap betweennormals and diabetics for the ¹³C breath test results than for the HOMAindex results. Table 1 compares diagnostic variables for the fastingplasma glucose, OGTT (WHO criteria), the HOMA index and the ¹³C breathtest. As not all subjects had fasting serum insulin values measured,diagnostic parameters for the ¹³C breath test in the subgroup that didhave their HOMA indexes calculated are presented in a separate column.For the purposes of this analysis, subject were classified as eitherdiabetic or non-diabetic based on the criterion of a fasting plasmaglucose of 7.0 or greater or a 2-hour OCTT value of 11.1 or greater. Theclassification of impaired fasting glucose was not used as thisdiagnosis is not readily verifiable from clinical data. From this table,it can be seen that the sensitivity, negative predictive value andoverall diagnostic accuracy of the ¹³C-glucose breath test is superiorto that of a fasting plasma glucose, OGTT or HOMA in the diagnosis oftype 2 diabetes. Similarly, the positive predictive value and thespecificity of the ¹³C-glucose is superior to that of the HOMA in makingthe diagnosis of type 2 diabetes. These latter two parameters are notapplicable to the fasting plasma glucose or OGTT, however, as anabnormality in either criterion would change the status of a subjectfrom “normal” to “diabetic”. Thus, based on a single measurement, therecan be no false positives by fasting plasma glucose or OGTT. Indeed, onesupposedly normal subject did have a fasting plasma glucose of 7.0 butfor purposes of this analysis, was still considered “normal”. It isnoteworthy that this same individual was categorized as “diabetic” onthe basis of the ¹³C breath test. If agreement between two fasting bloodglucoses is used as a basis for diagnosis, then the estimatedsensitivity of a FPG was 37%, specificity 82%, PPV 74%, NPV 48% anddiagnostic accuracy 55%. However, these values are estimates, using thefasting capillary glucose as a “second FPG”, taking into account anexpected 15% lower glucose result for the capillary glucose compared tothe FPG. Thus, the requirement for confirmation of any single diagnosticvalue by a repeat value would, as expected, decrease sensitivity butincrease specificity.

[0166]FIG. 6 demonstrates the relationship between the 1.5-hour¹³C-glucose result and the HOMA. As can be seen, a significantcorrelation exists between the two indices. FIG. 7 shows the ROC plotfor the 1.5-hour ¹³C-glucose breath result. From this figure, a cutoffof 9.0 seems to provide an optimal criterion for differentiatingdiabetic versus non-diabetic.

[0167] Logistic regression based on clinical status as the dependentvariable, and the 1.5-hour ¹³C breath test result, HOMA, age, BMI andsex as independent variables, gave an R² value of 0.53. Only the1.5-hour ¹³C breath test result gave a significant partial correlationcoefficient. When the logistic regression was repeated using either the1.5-hour ¹³C breath test result or the HOMA, but not both, in additionto the other variables, only the ¹³C breath test result gave asignificant partial correlation coefficient for the former regression.When the HOMA was used, significant partial correlations were obtainedfor age and HOMA. The R² for the former regression was 48 and for thelatter was 0.32. Thus the ¹³C breath test appears to be the strongestpredictor of diabetic status.

[0168] Further variations and modification of the present invention willbe apparent to those skilled in the art and are intended to beencompassed by the specification and claims appended hereto. TABLE 1Diagnostic Parameters for the Various Tests fpg WHO HOMA ¹³C breath ¹³Cbreath* sensitivity 43 62 67 73 75 specificity (97) (95) 67 92 84 PPV(96) (92) 64 90 79 NPV 52 61 70 77 81 DA 64 74 67 79 80

What is claimed is:
 1. A diagnostic kit for the determination ofglycemic control in a subject comprising: (a) a predetermined quantityof ¹³C-enriched glucose; and (b) a breath collection container.
 2. Adiagnostic kit according to claim 1 further comprising a plurality ofbreath collection containers.
 3. A diagnostic kit according to claim 1for use in the diagnosis of diabetes.
 4. A diagnostic kit according toclaim 1 for use in the diagnosis of insulin resistance.
 5. A diagnostickit according to claim 1 for use in the diagnosis of gestationaldiabetes.
 6. A diagnostic kit according to claim 1 for use in thedetermination of adequacy of antihyperglycemic therapy.
 7. A diagnostickit according to claim 1 wherein the ¹³C-enriched glucose is uniformlyenriched.
 8. A diagnostic kit according to claim 1 further comprising atube that is adapted for the transfer of the breath of a subject intothe breath collection container.
 9. A diagnostic kit according to claim2 further comprising a set of instructions wherein the instructionsdirect the subject to collect a first breath sample in a first breathcollection container, ingest the ¹³C-enriched glucose and collect asecond breath sample in a second breath container at a time point thatis about 90 minutes after ingestion of the ¹³C-enriched glucose.
 10. Theuse of ¹³C-enriched glucose for the determination of glycemic control ina subject.
 11. ¹³C-enriched glucose for use in the manufacture of adiagnostic kit for the determination of glycemic control in a subject.12. The ¹³C-enriched glucose of claim 11 for use in the manufacture of adiagnostic kit for the detection of diabetes.
 13. The ¹³C-enrichedglucose of claim 11 for use in the manufacture of a diagnostic kit forthe detection of gestational diabetes.
 14. The ¹³C-enriched glucose ofclaim 11 for use in the manufacture of a diagnostic kit for thedetection of insulin resistance.
 15. The ¹³C-enriched glucose of claim11 for use in the manufacture of a diagnostic kit for the determinationof adequacy of antihyperglycemic therapy.
 16. A diagnostic kit for thedetermination of glycemic control in normal, diabetic and insulinresistant subjects by comparing blood glucose levels with breath levelsof ¹³C-enriched CO₂ comprising: (a) a predetermined quantity of¹³C-enriched glucose; (b) a breath collection container; and (c) a bloodsampling device.
 17. A method of diagnosing a condition in a subject,said condition selected from the group consisting of diabetes, insulinresistance impaired glucose tolerance, impaired fasting glucose andgestational diabetes, said method comprising: a) collecting a firstbreath sample from said subject in a first breath collection container;b) administering ¹³C-enriched glucose to said subject; c) collecting asecond breath sample from said subject in a second breath container at atime point after administration of said ¹³C-enriched glucose; d)measuring the ¹³CO₂ in each of said first and second breath samples; ande) comparing the amount of ¹³CO₂ in said second breath sample with theamount of ¹³CO₂ in said first breath sample, wherein the presence ofless ¹³CO₂ in said second breath sample compared to normal controlvalues indicates the presence of said condition.
 18. The method of claim17, wherein said comparison is made by choosing a cutoff of ROC valueswherein the sensitivity and specificity are such as to maximizediagnostic accuracy.
 19. The method of claim 18, wherein said conditionis insulin resistance and said range of ROC values is 8 to
 10. 20. Themethod of claim 19, said ROC value is
 9. 21. A method of predicting asubject's risk of developing diabetes, said method comprising: a)collecting a first breath sample from said subject in a first breathcollection container; b) administering ¹³C-enriched glucose to saidsubject; c) collecting a second breath sample from said subject in asecond breath container at a time point after administration of said¹³C-enriched glucose; d) measuring the ¹³CO₂ in each of said first andsecond breath samples; and e) comparing the amount of ¹³CO₂ in saidsecond breath sample with the amount of ¹³CO₂ in said first breathsample, wherein the presence of less ¹³CO₂ in said second breath samplecompared to normal control values indicates risk of developing diabetes.21. The method of claim 21, wherein said comparison is made by choosinga cutoff of ROC values wherein the sensitivity and specificity are suchas to maximize diagnostic accuracy.
 22. The method of claim 21, whereinsaid range of ROC values is 8 to
 10. 23. The method of claim 22, saidROC value is 9.